Development of an Enhanced Recovery After Surgery Surgical Safety Checklist Through a Modified Delphi Process
Authors: Mercedes Pilkington, Gregg Nelson, Christy Cauley, Kari Holder, Olle Ljungqvist, George Molina, Ravi Oodit, Mary E. Brindle, Adrian Alvarez, Ainsley Cardosa-Wagner, Alan Lee, Alexander Gregory, Allyson R Cochran, Alon Altman, Amaniel Kefleyesus, Anna Cameron, Anna Fagotti, Anne Fabrizio, Antonio Gil-Moreno, Aziz Babaier, B B Pultram, Basile Pache, Bernhard Riedel, Brent Jim, Caitlin Jago, Chahin Achtari, Chris Jones, Chris Noss, Christa Aubrey, Christina Fotopoulou, Claire Temple-Oberle, Claire Warden, Claude Laflamme, Dionisios Vrochides, Emile Coetzee, Enrique Chacon, Ester Miralpeix, Eugenio Panieri, Geetu Bhandoria, Gretchen Glaser, Hans D de Boer, Henriette Smid, Jackie Thomas, Javier Ripolles-Melchor, Jeffrey Huang, Jessica Bennett, Joseph C Dort, Katharine McGinigle, Katherine Arendt, Kevin Elias, Kwang Yeong How, Larissa Meyer, Laura Hopkins, Lena Wijk, Lesley Roberts, Limor Helpman, Lloyd Mack, Mairead Burns, Manuel Roxas, Marianna Sioson, Martin Hubner, Michael Scott, Michael Yang, Mohammed Alruwaisan, Nikolaos Thomakos, Olivia Sgarbura, Pamela Chu, Pascal-André Vendittoli, Pat Trudeau, Pedro Ramirez, Rachelle Findley, Rakesh Arora, Rebecca Stone, Sarah Ferguson, Sean Dowdy, Sophia Pin, Steven Bisch, Sumer Wallace, Timothy Rockall, Timothy Paul, Valerie Addor
Journal: JAMA Network Open (2023)

Importance Enhanced Recovery After Surgery (ERAS) guidelines and the World Health Organization Surgical Safety Checklist (SSC) are 2 well-established tools for optimizing patient outcomes perioperatively. Objective To integrate the 2 tools to facilitate key perioperative decision-making. Evidence Review Snowball sampling recruited international ERAS users from multiple clinical specialties. A 3-round modified Delphi consensus model was used to evaluate 27 colorectal or gynecologic oncology ERAS recommendations for appropriateness to include in an ERAS SSC. Items attaining potential consensus (65%-69% agreement) or consensus (≥70% agreement) were used to develop ERAS-specific SSC prompts. These proposed prompts were evaluated in a second round by the panelists with regard to inclusion, modification, or exclusion. A final round of interactive discussion using quantitative consensus and qualitative comments was used to produce an ERAS-specific SSC. The panel of ERAS experts included surgeons, anesthesiologists, and nurses within diverse practice settings from 19 countries. Final analysis was conducted in May 2022. Findings Round 1 was completed by 105 experts from 18 countries. Eleven ERAS components met criteria for development into an SSC prompt. Round 2 was completed by 88 experts. There was universal consensus (≥70% agreement) to include all 37 proposed prompts within the 3-part ERAS-specific SSC (used prior to induction of anesthesia, skin incision, and leaving the operating theater). A third round of qualitative comment review and expert discussion was used to produce a final ERAS-specific SSC that expands on the current WHO SSC to include discussion of analgesia strategies, nausea prevention, appropriate fasting, fluid management, anesthetic protocols, appropriate skin preparation, deep vein thrombosis prophylaxis, hypothermia prevention, use of foley catheters, and surgical access. The final products of this work included an ERAS-specific SSC ready for implementation and a set of recommendations to integrate ERAS elements into existing SSCs. Conclusions and Relevance The SSC could be modified to align with ERAS recommendations for patients undergoing major surgery within an ERAS protocol. The stakeholder- and expert-generated ERAS SSC could be adopted directly, or the recommendations for modification could be applied to an existing institutional SSC to facilitate implementation.